Change Worksheet

PAPERWORK REDUCTION ACT

CHANGE WORKSHEET

Agency/Subagency: Commerce/Census/SSSD		OMB Control Number 0607-0013
Enter only items that change Current Record New Record
Agency form numbers(s)
Annual reporting and recordkeeping hour burden
Number of respondents
Total annual responses
Percent of these responses collected electronically	%	%
Total annual hours
Difference
Explanation of difference Program change Adjustment
Annual reporting and recordkeeping cost burden (in thousands of dollars)
Total annualized Capital/Startup costs
Total annual costs (O&M)
Total annualized cost requested
Difference
Explanation of difference Program change Adjustment
Other Change** According to the terms of clearance on OMB’s 12/8/2006 Notice of Action for this information collection, final forms are to be submitted prior to usage. Here are those forms.
Signature of Senior Official or designee:	Date:	For OIRA Use __________________________ __________________________

**This form cannot be used to extend an expiration date.

OMB 83-C 10/95